Eating Disorders Often Missed in Men

Action Points

Note that this qualitative study of 10 men with eating disorders suggests that gender bias may play a role in delayed diagnosis.

Be aware that larger studies will be necessary to elucidate the epidemiology of eating disorders in men.

Young men with eating disorders (EDs) -- along with their friends, families, and even some healthcare providers -- often fail to recognize their symptoms, primarily because EDs are perceived as afflicting teenage girls, a small qualitative study found.

"The culturally prevalent view that EDs largely affect teenage girls meant that many of these young men only recognized their behaviors and experiences as possible symptoms of an ED after a protracted delay, mitigating possibilities of early intervention and improved prognosis," wrote Ulla Räisänen, MA, of the University of Oxford in England and her co-author Kate Hunt, PhD, of the University of Glasgow in Scotland, in BMJ Open.

While the young men and the families in this study failed to recognize signs of EDs promptly because of this cultural gender bias, some of the primary care physicians who saw them failed to recognize the signs, too -- and for the same reason, the authors said.

In some cases, wrote Räisänen and Hunt, these physicians explicitly dismissed the young mens' symptoms because of their gender.

This may be partly because the construct of EDs as a female illness "has been embedded in clinical practice," wrote Räisänen and Hunt. Until 2013, they noted, the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) included amenorrhea as a diagnostic criteria for anorexia nervosa (AN).

Some physicians were slow to treat, even when patients were very ill, Räisänen told MedPage Today, via email. The problem "is certainly something that requires much more attention and awareness," she said.

"It's very disheartening," Willo Wisotsky, PhD, a psychologist at the Center for Weight Management at Syosset Hospital in New York, told MedPage Today. This pathology "has been out there," she said. This study, she said, brings awareness to the fact that "we can't let this patient population go unrecognized."

The findings were part of a larger qualitative research interview project, in which the researchers interviewed 39 young people (29 women and 10 men) between the ages of 16 and 25 with eating disorders who lived in the U.K. None were in inpatient treatment at the time of the interviews.

For this paper, the authors performed a more detailed analysis of the 10 men included in the study. All interviews took place in the interviewee's home or a meeting room, and lasted between 50 minutes and 2 hours.

All of the men with AN described skipping meals, selling their school lunches, restricting calorie intake and, ultimately, going days without food, the researchers said. Men with BN described comfort eating or purging after large meals.

"These behaviors usually developed over months, eventually becoming habitual," the authors wrote. "The men described developing daily routines around eating and weight management, such as obsessive calorie counting, exercise, and self-weighing."

Self-harming and increasing isolation was also not uncommon, the researchers said.

However, it took all of the men time to recognize their symptoms as indicative of an eating disorder, the researchers said, primarily because the presumed eating disorders were something that happened only to girls.

"Indeed, all the men described having no or very little awareness of EDs in men; hence, the possibility that their symptoms could be caused by an ED, rather than reflecting idiosyncratic behaviors, was not readily considered an explanation," the authors wrote.

One participant said he thought EDs were something that happened to "'fragile teenage girls [who are] very emotional,'" the authors reported.

What's more, most patient information is aimed at young women, the authors said, so that even if the young men were to seek out information about their symptoms, they might not recognize themselves in it.

"Much patient information on EDs fails to feature men or discusses issues for women, such as the impact of food starvation on female fertility," the authors said.

Physicians Slow to Diagnose

Many healthcare providers who saw these men at various stages of their disease failed to recognize the problem, according to the researchers. One treated a patient for "gastric problems" for a year, not suspecting that there might be psychological reasons for his vomiting and weight loss.

Even when young men got to the stage of admitting they had a problem, their encounter with the healthcare system was not necessarily positive. "Several men reported having to go to the [family physician] repeatedly before they felt they were taken seriously or referred," the authors wrote.

In a few cases the ED was missed or misdiagnosed. "Participant 2 was initially told he was 'going through a teenage fad,' until his mother went to see the [family physician] on her own," the authors said.

When participant 3 confessed his long-standing bingeing and purging to his doctor, the doctor "actively rejected a diagnosis of BN" and told the young man that he was depressed and prescribed antidepressants.

"He said to me, 'You haven't got bulimia, you're just depressed,'" this young man recounted. The young man said he was "quite confident" that the fact that he was male rather than female had confused the doctor.

"'You know, I didn't live up to the stereotype of being young and female,'" he said in his interview. "'It had sort of nothing to do with body image or weight or anything like that. I think that might have confused the doctor a little bit.'"

Another patient was told by a gastroenterologist he consulted -- after engaging in prolonged vomiting behavior and experiencing severe weight loss -- that his problems were not physical but psychological. Rather than refer him for psychological treatment, however, the gastroenterologist told the young man to "man up" and "not be weak," the patient said.

This young man's problems were recognized only after he was admitted to an emergency room after a suicide attempt. He was then referred to an outpatient ED clinic for intensive treatment, the authors said.

An Emerging Problem

It is not clear how many men have EDs, in part because of the cultural barriers that keep men from recognizing the signs and getting help and because of the lack of understanding and training by healthcare providers, the authors said.

"A commonly cited estimate, whose provenance is unclear, is that 10% of clinical ED cases occur in men, but some data suggest that this prevalence could be as high as 25%," the authors wrote.

Despite the uncertainty about prevalence, the authors said, "the incidence of EDs in men is rising." Dieting in men is on the rise as well, said Wisotsky.

Evidence on prognosis by gender is limited, the authors said, but at least one recent cohort study reported that treatment outcomes were better for men than women, when measured by regaining of weight and lack of relapse.

However, the later EDs are diagnosed, the "smaller the possibility of recovery and effective therapeutic interventions, leading to increased risk of serious sequelae including mortality," the authors wrote.

This study was limited to the experience of young men with EDs and does not contribute to understanding of the disease in older men, the authors noted.

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